Labels, laws and access to health care :
How history continues to affect health-care access for First Nations and Métis women

Access to health services differs among Aboriginal people. Understanding the history behind these differences and what they mean for women now is critical to improving health services used by Aboriginal women.

Indian, Métis and Inuit people are all recognized as Aboriginal people in the Constitution of Canada. However, there are differences in legal status within and among these groups that determine what health services they are entitled to receive. Often the word “Aboriginal” is used as a blanket term, when researchers and policy-makers actually should be looking more closely at specific groups within that population.

To address these issues, researchers at the Prairie Women's Health Centre of Excellence (PWHCE) wrote the paper, Entitlements and Health Services for First Nations and Métis Women in Manitoba and Saskatchewan.

“The first idea of developing this report came from a member of our Board who was frustrated that many policy-makers, researchers and the women with whom she works don't understand why these terms are so very important and that they are hugely important when it comes to health-care access,” says Margaret Haworth-Brockman, Executive Director at PWHCE.

Part 1 of the report reviews the history behind the different entitlements to health services in Canada and outlines current developments. Part 2 provides information about the health services available to First Nations and Métis women. A qualitative research project, described in Part 3, documents the experience of front-line workers who work with Métis and First Nations women and provides their suggestions for reducing barriers to good health. And Part 4 provides suggestions for policy-makers and researchers, based on the findings of the preceding sections.

In keeping with PWHCE’s mandate, the focus is specifically on Manitoba and Saskatchewan and, in this case, on First Nations and Métis people, who comprise the vast majority of Aboriginal people in the two provinces.

History’s long shadow

Entitlements to health-care services are complicated by over 400 years of colonization and more than 150 years of legislation. In Manitoba and Saskatchewan, the early land treaties set principles of federal responsibility for many services, including health care. Members of First Nations were referred to as “Indians” by the Europeans. Under the Indian Act, First Nations individuals who were members of Indian Bands that had signed treaties (or other agreements) were defined as having “Status.” People with Status are entitled to access the Non-Insured Health Benefits Program of the federal government and other services. However, some Indian people either never did have Status or lost it due to provisions of the Indian Act and are classified as non-Status. As a result they are not eligible for the federal services. Bill C-31 was introduced in 1985 for several reasons, including the move to restore Status to women who had lost their Status through marriage to a man without Status. While the Bill was intended to address some problems, it has introduced another layer of complexity in communities and within families.

Complicated as the provisions for health care for First Nations, there is no such federal provision for Métis residents in Manitoba and Saskatchewan. Métis people were not included in the treaties and some did not even receive scrip (a government-issued certificate for land or money to compensate for loss of Aboriginal title). Métis residents are provided with only those provincial health-care services available to all residents.

Effects on access

Service providers interviewed for the PWHCE study reported that many factors affect women’s access to health services, but the different entitlements to health services have significant impacts on women’s daily lives. The rules determining what specific services are included in programs are complex and difficult to understand, and changes in policies create additional uncertainty. The confusion about what services are available to whom is compounded when members of the same family have different Status. There are many communities in Manitoba and Saskatchewan (Cross Lake and The Pas, for example) where reserve and non-reserve lands are adjacent to each other and the residents are involved in both communities, but cannot necessarily seek or receive the same health-care services. One person may get flown to Winnipeg for a medical appointment, while her neighbour or cousin across the road has to take the bus for 12 hours.

"It almost seems like the general population doesn't understand that there's specific benefits for each of us and if you are First Nations you can access as long as you have that 10-digit number but First Nation women without Treaty Status, Métis women, and other women are distinctly different and if they do not have that 10-digit number they do not have access to the same kinds of services and programs." – Service Provider.

Health research and policy

New policy-related research and policy development are important to improving health services and health status. This work may be carried out by Canadian-based or international researchers who may not be aware of history and legislative developments in Canada.

PWHCE’s paper on health entitlements emphasizes that researchers and policy analysts must be clear about whom, and with whom, they are conducting their studies. Any study examining determinants of health, healthy living, health-care access, wait times, or service provision must be specific about the populations involved and their entitlements to health-care services. Researchers must bear in mind that, as mentioned, even members of the same family may have different entitlements to health care. Analysis of health-care access requires a consideration of history and entitlements to set the context fully, as it will affect results and subsequent recommendations.

Information gathering for policy purposes should include news items, reports and consultations that draw on and recognize the views of people with differing health-care entitlements. And naturally, they also need to recognize the differences between men and women regarding determinants of health, health status and health services accessed.

In decision-making processes, it is also critical to involve men and women with different health entitlements and access to services. This includes considering Status as well as geographic location, in particular. Protocols for decision making and appropriate consultation methods will vary by community. Communication about consultations and policy recommendations also needs to take into account the approaches that will work successfully with Aboriginal men and women locally.

Aboriginal organizations are now taking more of a lead in guiding new research that is culturally appropriate. Protocols and ethical standards have been developed for doing research with, for and by Aboriginal women.

Data sources and limitations

Having a Register of First Nations people with Indian Status means that federal and provincial administrative data such as vital statistics and statistics on the use of health services are more readily available. For example, health data can be retrieved about people who voluntarily declare their Status to Manitoba Health or Saskatchewan Health, including separate data for women and men. However, there are wrinkles in the system. The Manitoba Vital Statistics registry of deaths, for example, includes as “First Nations” all those, and only those, who were residents of a First Nations reserve when they died.

For non-Status Indian people or Métis people this type of data is not available because they are not identified separately in health-care records.

At Statistics Canada, survey and census respondents self-identify as having North American Indian, Métis or Inuit ancestry, as members of an Indian band or First Nation, or as a Registered or Treaty Indian. However some First Nations reserves have refused to take part in national surveys (Census Canada, for example), and in other cases survey design has not included the people in northern territories, most of whom are Aboriginal, or residents of reserves (Canadian Community Health Surveys, for example). Separate data for women and men are available, but are not always presented in public reports.

Returning to the women

This study in Manitoba and Saskatchewan demonstrates that women do recognize the inconsistencies in the treatment of First Nations people with Status, those who do not have Status, and Métis people. Women health-care providers who were interviewed for the study and the women they work with recognize the various health determinants affecting women’s access to health services, and insist that these factors be considered and addressed. They also emphasize that work needs to be done to ensure a more sensible and equitable way to provide health services to all Aboriginal people, whether First Nations, Métis or Inuit.

Kathy Bent is an independent researcher and a research associate of PWHCE based in Manitoba. Joanne Havelock is a policy analyst with PWHCE and lives in Regina. Margaret Haworth-Brockman is the Executive Director of Prairie Women's Health Centre of Excellence and lives in Winnipeg.

To download a copy of the full report, Entitlements and Health Services for First Nations and Métis Women in Manitoba and Saskatchewan, visit the Prairie Women’s Health Centre of Excellence website at www.pwhce.ca

This retrospective from the Prairie Women’s Health Centre of Excellence (PWHCE) follows a decade of work in Saskatchewan and Manitoba, addressing the health needs of women in these two Prairie provinces.

PWHCE has shown leadership in health issues for Aboriginal women, women living in poverty, rural, remote and northern women, and gender-based analysis across Canada, and internationally. Fertile Ground, Healthy Harvest records the Centre’s successes and accomplishments over the past decade and presents plans for planting new seeds in the seasons ahead.

Selected photos and commentary from two PhotoVoice projects in Winnipeg and Saskatoon are included throughout Fertile Ground.